Magnification narrow-band imaging for the diagnosis of early gastric cancer: a review of the Japanese literature for the Western endoscopist

Endoscopic Submucosal Dissection for Gastric Tube Carcinoma after Esophagectomy Contributes to Long-Term Outcomes

The incidence of gastric tube carcinoma (GTC) after esophagectomy for esophageal carcinoma has increased in recent years. Surgical removal of the reconstructed gastric tube is associated with high mortality, and endoscopic submucosal dissection (ESD) is a promising alternative. There are limited reports of ESD for GTC. This study investigated the efficacy and safety of ESD in GTC. This single-center retrospective study examined patients who underwent ESD for GTC after esophagectomy at our institution between 2003 and 2018. The curability of GTC with ESD was evaluated histologically according to the Japanese Gastric Cancer Treatment Guidelines. Patient characteristics and procedural and long-term outcomes were analyzed. Overall, 31 patients (29 men and 2 women; median age, 73 years) with 45 GTC lesions underwent ESD. The mean period between primary esophagectomy and the diagnosis of GTC was 10.6 years. Bleeding during ESD was noted in two patients (6.5%). No other adverse or fatal events such as perforation were noted. Complete resection and curative resection were documented in 80.6% and 48.4% of cases, respectively. The 3-year and 5-year overall survival rates were 67.6% and 47.7%, respectively. The 3-year and 5-year disease-specific survival rates were 100% and 92.9%, respectively. One patient died of GTC, and fourteen patients died of other diseases, including primary carcinoma in five cases. ESD was safe and provided good long-term outcomes in patients with GTC. Regular long-term gastroscopy is required for the early detection of GTC. Patients with GTC after esophagectomy for esophageal carcinoma have a high risk of other primary carcinomas or comorbidities after ESD.

New Closure Method Using Loop and Open-Close Clips after Endoscopic Submucosal Dissection of Stomach and Colon Lesions

Endoscopic submucosal dissection (ESD) and en bloc resection of stomach and colon tumors have become common. However, mucosal defects resulting from ESD may cause delayed bleeding and perforation. To prevent adverse events, we developed a new clip closure technique, namely, the loop and open–close clip closure method (LOCCM), and aimed to examine its efficacy after ESD for stomach and colon tumors. The LOCCM uses loop and open–close clips. Here, the open–close clip was used to grasp the loop to bring it to the edge of the post-ESD mucosal defect. Another clip with a loop was then inserted into the opposite edge and clipped to the contralateral mucosa to pull both edges together. Once apposed, additional clips facilitated complete closure. The LOCCM was performed in 19 patients after ESD at Tottori University between October 2020 and March 2021. The outcomes retrospectively analyzed were the LOCCM success and adverse event rates. The complete closure rate using LOCCM was 89.5% and none of the patients had post-ESD bleeding or perforation. The results show that LOCCM is an effective and safe closure technique for mucosal defects after stomach and colon ESD to prevent bleeding and perforation.

Taking the Next Steps in Endoscopic Visual Assessment of Barrett's Esophagus: A Pilot Study

Purpose

Patients with Barrett's esophagus (BE) undergo surveillance endoscopies to assess for pre-cancerous changes. We developed a simple endoscopic classification method for predicting non-dysplastic BE (NDBE), low-grade dysplasia (LGD)/indefinite for dysplasia (ID) and high-grade dysplasia (HGD)/early esophageal adenocarcinoma (EAC).

Patients and Methods

Twenty-two patients with BE underwent endoscopy using the PENTAX Medical MagniView gastroscope and OPTIVISTA processor. Sixty-six video-still images were analyzed to characterize the microsurface, microvasculature and the presence of a demarcation line. Class A was characterized by regular microvascular and microsurface patterns and absence of a demarcation line, class B by changes in the microvascular and/or microsurface patterns compared to the background mucosa with presence of a demarcation line, and class C by irregular microvascular and/or irregular microsurface patterns with presence of a demarcation line.

Results

Of the class A images, 97.9% were NDBE. For class B, 69.2% were LGD/ID and 30.8% NDBE. One hundred percent of the class C samples were HGD/EAC. The sensitivity of our classification system was 93.8%, specificity 92%, positive predictive value 78.9%, negative predictive value 97.9% and an accuracy 92.4%.

Conclusion

In this study, we developed a simple classification system for the prediction of NDBE, LGD/ID and HGD/EAC. Its real-time clinical applicability will be validated prospectively.

A comprehensive update on early gastric cancer: defining terms, etiology, and alarming risk factors

INTRODUCTION

Early gastric cancer (EGC) is a well-defined gastric malignancy that is limited to the mucosa or submucosa, irrespective of lymph node metastasis. At an early stage, gastric cancer often does not cause symptoms until it becomes advanced, and it is a heterogeneous disease and usually encountered in its late stages.

AREA COVERED

This comprehensive review will provide a novel insight into the evaluation of EGC epidemiology, defining terms, extensive etiology and risk factors, and timely diagnosis since prevention is an essential approach for controlling this cancer and reducing its morbidity and mortality.

EXPERT OPINION

The causative manner of EGC is complex and multifactorial. In recent years, researchers have made significant contributions to understanding the etiology and pathogenesis of EGC, and standardization in the evaluation of disease activity. Though the incidence of this cancer is steadily declining in some advanced societies owing to appropriate interventions, there remains a serious threat to health in developing nations. Early detection of resectable gastric cancer is crucial for better patient outcomes.

Controversies in EUS: Do we need miniprobes?

This is the fifth in a series of papers entitled "Controversies in EUS." In the current paper, we deal with high-resolution catheter probes, otherwise known as EUS miniprobes (EUS-MPs). The application of miniprobes for early carcinomas in the entire intestinal tract, for subepithelial lesions, and for findings in the bile duct and pancreatic duct as well as endobronchial use is critically discussed. Submucous lesions, especially in the colon, but also early carcinomas in special cases are considered the most important indications. The argument is illustrated by numerous examples.

Well-differentiated adenocarcinoma may be misdiagnosed as gastritis cystica profunda

Gastric cancer (GC) is one of the most common malignant tumors in China. The low detection rate of early GC is one of the reasons for its high mortality rate. Thanks to the application of new gastroscopy technology, the detection rate of early GC has increased. Highly differentiated adenocarcinoma accounts for about 70% of all early GC cases; however, well-differentiated adenocarcinoma is difficult to diagnose because of its non-significant structural abnormality and cellular atypia. Gastritis cystica profunda is a rare disease characterized by the presence of the gastric intrinsic gland in the muscularis mucosa and/or submucosa, which is easily confused with highly differentiated adenocarcinoma. Therefore, attention should be paid to the identification of these two different entities in the clinical work.

Narrow-band imaging versus white light versus mapping biopsy for gastric intestinal metaplasia: a prospective blinded trial

BACKGROUND AND AIMS

Gastric intestinal metaplasia (GIM) is a gastric cancer precursor. Narrow-band imaging (NBI) may improve detection of GIM. We compared detection of GIM with high-definition white-light (HD-WL) endoscopy, NBI, and mapping biopsies in a population with increased gastric cancer risk.

METHODS

Patients undergoing upper endoscopy had HD-WL examination by 1 endoscopist, followed by an NBI examination by a second endoscopist blinded to HD-WL findings. The location of abnormalities detected by HD-WL and NBI were recorded by a research coordinator, and targeted biopsies of abnormal areas were performed after NBI. Subsequently, 5 mapping biopsies were performed per patient. Biopsy specimens were read by a pathologist blinded to mode of acquisition. The primary outcome was the proportion of patients with GIM.

RESULTS

We enrolled 112 patients: 107 (96%) were Hispanic or Asian, and 34 (30%) had GIM. Higher proportions of patients with GIM were detected by NBI (22/34 [65%]) and mapping (26/34 [76%]) versus HD-WL (10/34 [29%]) (P < .005 for both comparisons). GIM was detected by NBI in only 6 patients and only by mapping biopsy in 10 patients; no patient had GIM detected solely by HD-WL. Higher proportions of sites with GIM also were detected with NBI (30/57 [53%]) and mapping biopsies (38/57 [67%]) than HD-WL (16/57 [28%]) (P < .005 for both comparisons). The median number of biopsies per patient with mapping biopsies (5) was significantly higher than with NBI (2) or HD-WL (1).

CONCLUSIONS

HD-WL endoscopy is insufficient for detection of GIM in patients at increased risk for gastric cancer. NBI-targeted biopsies plus mapping biopsies should be used. (Clinical trial registration number: NCT02197351.).

A guide to multimodal endoscopy imaging for gastrointestinal malignancy - an early indicator

Multimodality imaging is an essential aspect of endoscopic surveillance for the detection of neoplastic lesions, such as dysplasia or intramucosal cancer, because it improves the efficacy of endoscopic surveillance and therapeutic procedures in the gastrointestinal tract. This approach reveals mucosal abnormalities that cannot be detected by standard endoscopy. Currently, these imaging techniques are divided into those for primary detection and those for targeted imaging and characterization, the latter being used to visualize areas of interest in detail and permit histological evaluation. This Review outlines the use of virtual chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and volumetric laser endomicroscopy as new imaging techniques for diagnostic investigation of the gastrointestinal tract. Insights into use of multimodal endoscopic imaging for early disease detection, in particular for pre-malignant lesions, in the oesophagus, stomach and colon are described.

Advanced gastrointestinal endoscopic imaging for inflammatory bowel diseases

Gastrointestinal luminal endoscopy is of paramount importance for diagnosis, monitoring and dysplasia surveillance in patients with both, Crohn’s disease and ulcerative colitis. Moreover, with the recent recognition that mucosal healing is directly linked to the clinical outcome of patients with inflammatory bowel disorders, a growing demand exists for the precise, timely and detailed endoscopic assessment of superficial mucosal layer. Further, the novel field of molecular imaging has tremendously expanded the clinical utility and applications of modern endoscopy, now encompassing not only diagnosis, surveillance, and treatment but also the prediction of individual therapeutic responses. Within this review, we describe how novel endoscopic approaches and advanced endoscopic imaging methods such as high definition and high magnification endoscopy, dye-based and dye-less chromoendoscopy, confocal laser endomicroscopy, endocytoscopy and molecular imaging now allow for the precise and ultrastructural assessment of mucosal inflammation and describe the potential of these techniques for dysplasia detection.

Early Gastric Cancer: Current Advances of Endoscopic Diagnosis and Treatment

Endoscopy is a major method for early gastric cancer screening because of its high detection rate, but its diagnostic accuracy depends heavily on the availability of endoscopic instruments. Many novel endoscopic techniques have been shown to increase the diagnostic yield of early gastric cancer. With the improved detection rate of EGC, the endoscopic treatment has become widespread due to advances in the instruments available and endoscopist's experience. The aim of this review is to summarize frequently-used endoscopic diagnosis and treatment in early gastric cancer (EGC).

From the surface to the single cell: Novel endoscopic approaches in inflammatory bowel disease

Inflammatory bowel diseases (IBD) comprise the two major entities Crohn’s disease and ulcerative colitis and endoscopic imaging of the gastrointestinal tract has always been an integral and central part in the management of IBD patients. Within the recent years, mucosal healing emerged as a key treatment goal in IBD that substantially decides about the clinical outcome of IBD patients, thereby demanding for a precise, timely and detailed endoscopic assessment of the mucosal inflammation associated with IBD. Further, molecular imaging has tremendously expanded the clinical utility and applications of modern endoscopy, now encompassing not only diagnosis, surveillance, and treatment but also the prediction of individual therapy response. Within this review we describe novel endoscopic approaches and advanced endoscopic imaging methods for the diagnosis, treatment and surveillance of IBD patients. We begin by providing an overview over novel and advanced imaging techniques such as magnification endoscopy and dye-based and dye-less chromoendoscopy, endomicroscopy and endocytoscopy. We then describe how these techniques can be utilized for the precise and ultrastructural assessment of mucosal inflammation and dysplasia development associated with IBD and outline how they have enabled the endoscopist to gain insight onto the cellular level in real-time. Finally, we provide an outlook on how molecular imaging has rapidly evolved in the recent past and can be used to make individual predictions about the therapeutic response towards biological treatment.

Circumferential distribution and location of Mallory-Weiss tears: recent trends

BACKGROUND AND STUDY AIMS

Mallory-Weiss tears (MWTs) are not only a common cause of acute nonvariceal gastrointestinal bleeding but also an iatrogenic adverse event related to endoscopic procedures. However, changes in the clinical characteristics and endoscopic features of MWTs over the past decade have not been reported. The aim of this study was to investigate recent trends in the etiology and endoscopic features of MWTs.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with a diagnosis of MWT at our university hospital between August 2003 and September 2013. The information regarding etiology, clinical parameters, endoscopic findings, therapeutic interventions, and outcome was reviewed.

RESULTS

A total of 190 patients with MWTs were evaluated. More than half (n = 100) of the cases occurred during endoscopic procedures; cases related to alcohol consumption were less frequent (n = 13). MWTs were most frequently located in the lesser curvature of the stomach and right lateral wall (2 - to 4-o'clock position) of the esophagus, irrespective of the cause. The condition of more than 90 % of the patients (n = 179) was improved by conservative or endoscopic treatment, whereas 11 patients (5.8 %) required blood transfusion. Risk factors for blood transfusion were a longer laceration (odds ratio [OR] 2.3) and a location extending from the esophagus to the stomach (OR 5.3).

CONCLUSIONS

MWTs were frequently found on the right lateral wall (2 - to 4-o'clock position) of the esophagus aligned with the lesser curvature of the stomach, irrespective of etiology. Longer lacerations extending from the esophagus to the gastric cardia were associated with an elevated risk for bleeding and requirement for blood transfusion.

Expression of secreted phospholipase A2-Group IIA correlates with prognosis of gastric adenocarcinoma

The present study investigated the expression of secretory phospholipase A2-Group IIA (sPLA2-II) in gastric adenocarcinoma, in order to evaluate the correlation between sPLA2-II expression, and the clinicopathological features and prognosis of patients with gastric adenocarcinoma. Between January 2007 and April 2010, data were collected from 65 patients (44 males, 21 females; age range, 30-79 years; mean 66.7 ± 10.7 years). All patients exhibited a pathologically confirmed diagnosis of gastric adenocarcinoma. Endoscopic biopsy specimens of normal gastric mucosa from 11 of these patients were used as controls. Patients were subsequently followed-up at 3-month intervals, and survival data were recorded until April 2010. Expression of sPLA2-II in 65 gastric adenocarcinoma and 11 normal gastric mucosa specimens was evaluated via immunohistochemistry. A semi-quantitative method, consisting of evaluation of staining percentage and intensity, was utilized for immunohistochemical scoring, and the receiver operating characteristic curve method was applied to select a cut-off score for high and low sPLA2-II expression. The value of 8 was selected as the cut-off score, with maximum sensitivity and specificity. High sPLA2-II expression was observed in stage III/IV cases (83.3%; 40/48) and poorly differentiated cells (94.1%; 32/34), while sPLA2-II expression levels were observed to be significantly lower in stage I/II cases (52.9%; 9/17) and well and moderately differentiated cells (54.8%; 17/31; P=0.021 and P<0.001, respectively). There were no significant correlations observed between sPLA2-II expression and any other clinicopathological parameters, including gender, age, tumor diameter and Helicobacter pylori infection. Patients exhibiting low sPLA2-II expression experienced significantly improved overall survival (OS) and disease-free survival (DFS), compared with those exhibiting high sPLA2-II expression (P=0.043 and P=0.035, respectively). Multivariate analysis confirmed that high sPLA2-II expression may be an independent prognostic factor for OS [relative risk, 2.849; 95% confidence interval (CI), 1.088-7.459; P=0.033] and DFS (relative risk, 2.735; 95% CI, 1.104-6.776; P=0.030) in gastric adenocarcinoma. Therefore, sPLA2-II may be correlated with the histogenesis of gastric adenocarcinoma, and increased sPLA2-II expression may be an indicator of poor prognosis.

In vivo gastric mucosal histopathology using endocytoscopy

AIM: To study the ability of endocytoscopy to identify normal gastric mucosa and to exclude Helicobacter pylori (H. pylori) infection.

METHODS: Endocytoscopic examination of the gastric corpus and antrum was performed in 70 consecutive patients. Target biopsy specimens were also obtained from the assessed region and multiple H. pylori tests were performed. The normal endocytoscopy patterns of the corpus and antrum were divided into the normal pit-dominant type (n-Pit) or the normal papilla-dominant type (n-Pap), respectively characterized as either regular pits with capillary networks or round, smooth papillary structures with spiral capillaries. On the other hand, normal mucosa was defined as mucosa not demonstrating histological abnormalities, including inflammation and atrophy.

RESULTS: The sensitivity and specificity of n-Pit for normal mucosa in the gastric corpus were 94.4% and 97.1%, respectively, whereas those of n-Pap for normal mucosa in the antrum were 92.0% and 86.7%, respectively. The positive predictive values of n-Pit and n-Pap for H. pylori-negative tissue were 88.6% and 93.1%, respectively, and their negative predictive values for H. pylori-negative tissues were 42.9% and 41.5%, respectively. The inter-observer agreement for determining n-Pit and n-Pap for normal mucosa were 0.857 and 0.769, respectively, which is considered reliable.

CONCLUSION: N-Pit and n-Pap, seen using EC, are considered useful predictors of normal mucosa and the absence of H. pylori infection.

In vivo histopathology using endocytoscopy for non-neoplastic changes in the gastric mucosa: a prospective pilot study (with video)

BACKGROUND

Endocytoscopy (EC), as a novel ultrahigh magnification technology, enables in vivo histopathological diagnoses of the GI tract. EC is particularly exceptional when comparing dysplastic and neoplastic tissue with normal tissue. There are, however, no detailed data for minute or minimal changes in the gastric mucosa.

OBJECTIVE

To describe non-neoplastic EC patterns of the gastric mucosa correlated with histopathological findings and to determine any relationship with Helicobacter pylori (HP) infection.

DESIGN

A pilot prospective study.

SETTING

Tertiary care referral center.

PATIENTS

Sixty-four participants undergoing upper endoscopy for various indications.

METHODS

Antral mucosal patterns on EC were divided into 4 categories: type 1 (normal), each papilla/pit has round smooth structure; type 2 (gastritis), extended, notched, and distorted structure with some necrotic tissue; type 3(atrophy), neighboring papilla/pit take on a lobulated appearance; type 4 (intestinal metaplasia [IM]), goblet cells are identified in a completely stained crypt. Target biopsy specimens were obtained from the region identified with these patterns, and multiple HP tests were performed.

RESULTS

HP positivity was 0%, 40.9%, 50.0%, and 58.3% in types 1, 2, 3, and 4, respectively. The sensitivity and specificity of types 2+3+4 for HP positivity were 100％ and 42.5%, respectively. The positive predictive values of type 1 for normal, type 2 for chronic gastritis, type 3 for atrophic gastritis, and type 4 for IM were 100%, 62.5%, 40.0%, and 100%, respectively. The sensitivity and specificity of types 3+4 for atrophic gastritis to IM were 87.0% and 95.1%, respectively.

LIMITATIONS

Small, single-center, pilot study.

CONCLUSIONS

EC can differentiate gastric mucosal patterns of minimal, non-neoplastic change and appears to reliably exclude HP infection.

Advanced endoscopic imaging for gastric cancer assessment: new insights with new optics?

The most immediate strategy for improving survival of gastric cancer patients is secondary prevention through diagnosis of early gastric cancer either through screening or follow-up of individuals at high risk. Endoscopy examination is therefore of paramount importance and two general steps are to be known in assessing gastric mucosa - detection and characterization. Over the past decade, the advent of advanced endoscopic imaging technology led to diverse descriptions of these modalities reporting them to be useful in this setting. In this review, we aim at summarizing the current evidence on the use of advance imaging in individuals at high-risk (i.e., advance stages of gastric atrophy/intestinal metaplasia) and in those harbouring neoplastic lesions, and address its potential usefulness providing the readers a framework to use in daily practice. Further research is also suggested.